UMEM Educational Pearls - By Duyen Tran

Acute liver failure is defined as new and rapidly evolving hepatic dysfunction associated with neurologic dysfunction and coagulopathy (INR >1.5). Most common cause of death in these patients are multiorgan failure and sepsis. Drug-induced liver injuy most common cause in US, with viral hepatitis most common cause worldwide.

Management of complications associated with acute liver failure

• Hepatic encephlopathy: Administer lactulose orally or via enema if risk of aspiration. Goal is to slow progression to severe encephalopathy and minimize development of cerebral edema.
• Coagulopathy: Reverse if significant bleeding or if patient needs to have invasive procedure. FFP and 4-factor PCC not indicated in absence of bleeding. Additionally these patients may be vitamin-K deficient for which vitamin K can be given.
• Consider empiric antibiotics due to increased susceptibility to infection.
• Renal dysfunction: correct hypovolemia with fluid resuscitation. May require RRT, continuous preferred for hemodynamic stability.
• If persistent hypotension despite adequate volume resuscitation and pressors, IV hydrocortisone indicated as adrenal insufficiency is common in these patients.
• Early consultation with liver transplant center. King's College Criteria and MELD score are most commonly used prognostic tools.

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Clinical pearls for hypothermic cardiac arrest

• VA-ECMO is rewarming strategy of choice – consider transport/contacting nearest ECMO center whenever possible
  • HOPE score predicts survival probability after ECLS rewarming and may guide ECLS decision making. Predictors include age, sex, mechanism of hypothermia, CPR duration, potassium, and core temperature at admission
• If access to ECMO center is not available, use external and internal rewarming strategies: removing wet clothes, forced-air heating blankets, warmed IV fluids (38-42C), thoracic and/or peritoneal lavage
• High-quality continuous CPR is key. Use mechanical CPR when available
• Lack of consensus with regards to ACLS guidelines. European Resuscitation Council recommends up to 3 attempts at defibrillation and withholding epinephrine while core temp is < 30C. AHA states reasonable to follow standard ACLS algorithms. It has been suggested that administering up to 3 shocks and 3 doses of epinephrine while core temp is <30 C is a reasonable approach, with additional doses guided by clinical response
• Resuscitate until core temp is at least 32C (warm and dead). Once rewarmed, consider termination of resuscitation with persistent asystole or K >12

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Myocarditis is a potentially fatal inflammatory disorder of the heart. Viral infection is the most common cause but can also result from toxic, autoimmune, or other infectious etiologies. Complications include life-threatening dysrhythmias, heart failure, and fulminant myocarditis. Typically affects young patients (20-50 years old).

• Diagnosis can be challenging. Presentation can range from nonspecific symptoms and normal hemodynamics to cardiogenic shock.
• Dyspnea was found to be the most common presenting symptom in one study
• Other symptoms include fever, malaise, chest pain, palpitations, fatigue, nausea, vomiting
• Consider the diagnosis in young patient with suspected sepsis but worsens with IV fluids with signs of volume overload
• Initial assessment should include ECG, CBC, CMP, inflammatory markers, cardiac biomarkers, CXR. Obtaining an echo is important. Perform POCUS to assess for global hypokinesis, reduced EF, wall motion abnormalities, pericardial effusion, B-lines.

ED management pearls

• Initiate vasopressors and inotropic support if hemodynamically unstable: norepinephrine + inotropic agent (e.g. milrinone, dobutamine) is recommended. In a few studies, epinephrine was associated with increased mortality when used in cardiogenic shock.
• Diurese if evidence of volume overload
• NIPPV or intubation if respiratory failure
• Avoid NSAIDs which may worsen mortality
• Consider mechanical circulatory support (e.g. ECMO, IABP, VAD) in refractory hypotension despite appropriate medical therapy

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Intubation considerations

• Use large ET tube (at least 8.0 if possible): minimizes airway resistance, facilitates aggressive pulmonary toilet and bronchoscopy if needed
• Consider using ketamine as induction agent as it has bronchodilator properties and can maintain blood pressure
• Appropriate choices for initial sedation includes propofol, fentanyl, and ketamine

Vent management strategies

• No overall outcome differences between volume vs pressure control modes. Volume control has been recommended as initial mode due to familiarity and ensures your set tidal volume will be delivered.
• Goal is to minimize autoPEEP, which occurs from incomplete exhalation prior to initiation of next inhaled breath. This can be achieved by adjusting a few vent settings: decreasing RR, decreasing I:E ratio, decreasing inspiratory time, or increasing inspiratory flow rate. Allow for permissive hypercapnia, pH >7.2 has been advocated though precise target is unknown.
• If patient becomes hemodynamically unstable, consider first disconnecting the ventilator from the ET tube and manually decompress the chest to facilitate exhalation.
• Peak inspiratory pressures are expected to be high in the acute severe asthmatic. More important is to keep plateau pressures <30 cm H₂O to prevent lung injury.
• Don't forget to continue asthma-directed therapy. Administer albuterol via in-line nebulization unit of the vent.

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